Provider Demographics
NPI:1003024720
Name:PENNSYLVANIA ONCOLOGY HEMATOLOGY ASSOCIATES, PC
Entity Type:Organization
Organization Name:PENNSYLVANIA ONCOLOGY HEMATOLOGY ASSOCIATES, PC
Other - Org Name:PENNSYLVANIA ONCOLOGY HEMATOLOGY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SEC AND TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-829-6088
Mailing Address - Street 1:230 W WASHINGTON SQ
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-3500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:250 KING OF PRUSSIA RD
Practice Address - Street 2:STE 1B
Practice Address - City:RADNOR
Practice Address - State:PA
Practice Address - Zip Code:19087-5220
Practice Address - Country:US
Practice Address - Phone:610-902-5950
Practice Address - Fax:610-902-5959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD021663E332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009549220002Medicaid
PA0017646000004Medicaid
3987483OtherNCPDP PROVIDER IDENTIFICATION NUMBER